The cognitive dissonance of prescribing narcotics

I know a bit about the opioid epidemic ravaging America. My wife and I grew up in West Virginia and follow the news from home. I practice emergency medicine in rural South Carolina, and have worked in Georgia, North Carolina, Kentucky, and Indiana. I have seen the enemy, and it is terrible to behold.

The genesis of the epidemic has been covered over and over. It is a complex problem with an equally complex history. No sound-bite by politicians or government regulators can simplify it.

Many people and groups are working to stem the black tide of overdose deaths flowing across America. Health departments are offering counseling, as well as distributing naloxone (also known as Narcan) to reverse overdoses. Pharmacies are limiting the size of prescriptions filled.

States have databases to track opioid prescriptions and are monitoring prescribers more closely than ever. Physicians are being advised to give fewer opioids per prescription. State medical boards are also mandating that physicians receive more education on the topic.

Only a few years ago physicians were called heartless if they had reservations about prescribing opioids for pain not associated with cancer or serious trauma. Times and policies have changed, and the same physicians are considered dangerous for doing what they were explicitly directed to do before.

However, as we charge forward with assorted plans, programs, and schemes to address the opioid crisis, I want to explain why physicians sometimes find it hard not to give narcotics.

You see, we went into medicine with grand plans to save the dying, heal the sick and wounded, and ease the pain of the suffering. Those are noble goals, which helped us endure the process and become physicians.

But along the way, we were ill-prepared for the very real struggles of addiction. In addition, medical school didn’t teach us how to face the cognitive dissonance of being told to believe what patients say while simultaneously having good reason to believe they are lying. (Lying, that is, to either to feed their addiction or to obtain drugs to divert for illicit sales.)

This is tough stuff. Research is pretty clear in suggesting that many painful conditions are ultimately not best treated by narcotics. (A tough thing to sell to someone who has been inappropriately given narcotics for years.) Furthermore, some people with legitimate reasons to use opioids still become addicted. Young people with sickle cell disease often need the relief of narcotics, and through no fault of their own. The same is true for those with severe injuries that take months or years to heal. (If they heal at all.)

The situation is made more difficult because we still don’t have a “pain-o-meter.” Oh, we have that ludicrous and completely subjective pain scale. But it isn’t like a blood pressure or heart rate. And while some conditions are obviously painful, others aren’t so evident. Dental pain can be truly terrible without “looking” painful. (This is a thing often dismissed by those who have been able to afford good dental care their entire lives.) Back pain can be unverifiable, and so can the pain of ovarian cysts, the nerve pain of neuropathy, the torture of migraine headaches and many others.

Furthermore, real patients with real (often chronic) pain often have financial woes and can’t see a pain specialist or back surgeon. All too often these days, they can’t even see a family physician. Sometimes they have a pain emergency, after a surgery for instance, when their own physician is out of town.

So when we see that patient who has many suspicious prescriptions for pain medication in the state database, but who is crying real tears and being attended by worried family members, it’s not so easy to turn them down. Sometimes we say no; but it requires that the physician really have his or her “ducks in a row,” and ensure that the evidence is sufficiently strong to withhold opioid pain medications.

We’ve all been fooled and we’ll be fooled again. Because for a physician, pain is a frustrating mixture of the objective and the subjective. In the treatment of pain, we confront the very real misery of humans and balance it against the very real danger of overdose and death.

It’s easy to say “just stop giving them those prescriptions,” or, “oh he’s lying, he always does this.” But deep in our physician hearts we want to believe people. We want to do the right thing and ease the misery.

We hate this epidemic. We hate seeing lives lost and giving tragic news to the families of the dead. We grow weary of arguing, endlessly, about pain medications. And we resent being falsely accused of causing the whole mess.

Mind you, we have to own our fair share of it all. And some of us are worse than others. Physician run pill-mills, physicians too free with opioids, physicians themselves addicted; we’re sometimes part of the problem to be sure.

But don’t judge physicians too quickly or too harshly until you have looked into the crying eyes of a patient and said, firmly and with some sadness, “I’m not giving you a narcotic today.” And watched them walk away, wondering if you were right.